letters GUIDELINES
Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor. Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested. Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium. The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence. The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.
Letters Free Tissue Transfer in the Obese Patient: An Outcome and Cost Analysis in 1258 Consecutive Abdominally Based Reconstructions Sir:
W
e read with great interest the article by Fischer et al.1 published recently on breast reconstruction in the obese patient population. The deep inferior epigastric perforator (DIEP) flap has become a workhorse in autologous breast reconstruction2 and a very popular option for breast reconstruction because of the reduced donor-site morbidity and the additional benefit of an abdominoplasty, even more so in the obese patient with a distinct pannus. However, surgeons have to remain guarded over selecting patients for a DIEP flap procedure in the Copyright © 2014 by the American Society of Plastic Surgeons
presence of certain comorbid conditions. Obesity, especially class III obesity (body mass index >40 kg/m2), is a proven independent risk factor for complications during autologous breast reconstruction, with a higher risk of total flap loss, total major postoperative complications, and delayed abdominal wound healing.3 Interestingly, perforator flaps such as the DIEP flap or superficial inferior epigastric artery flap exhibit fewer postoperative donor-site complications compared with muscle-sparing transverse rectus abdominis muscle flaps, with comparable microsurgical outcomes.1 Therefore, the authors of the current study advise caution when offering this type of breast reconstruction to morbidly obese patients. In a different study, outcomes of breast reconstruction in over 600 patients were reviewed with a specific focus on comorbid conditions.4 The authors found a significantly increased rate of flap complications and a significantly higher rate of total flap loss, including donor-site complications in women with a body mass index greater than 30. However, they concluded that although patients should be advised to reduce their body weight, obesity should not be considered a contraindication to microsurgical breast reconstruction. Even in this patient cohort, DIEP flap reconstruction represents the technique of choice, with excellent aesthetic outcomes and high patient satisfaction. In light of these findings, we want to report our experience in bilateral microsurgical breast reconstruction in a superobese patient. A 44-year-old patient with a body mass index of 53.8 kg/m2 and with recurrence of a breast carcinoma on the right side presented to our service for autologous breast reconstruction. The patient had a positive family history of breast cancer (mother and grandmother) and with certain comorbid conditions such as diabetes mellitus, hypertension, hypothyroidism, extreme obesity with a massive abdominal pannus, and asthma bronchiale. Five years earlier, she underwent an oncoplastic resection of the upper exterior quadrant of the left breast with a simultaneous contralateral adaptive mastopexy and a sentinel lymph node biopsy in the left axilla. Postoperatively, the patient underwent radiotherapy and chemotherapy. Two years later, she had recurrence on both sides that was treated with lumpectomy. The patient presented to our office for breast reconstruction with bilateral hemi-DIEP flaps immediately following simultaneous bilateral mastectomy. The weight of the pannus was 4477 g; the weight of the left hemi-DIEP flap 1285 g and that of the right hemi-DIEP flap was 1314 g. Preoperatively, a perforator computed tomographic scan was obtained that showed good bilateral DIEP vessels. We first resected the lateral extensions of the pannus and proceeded to explore the perforator vessels on both sides under loupe magnification (Fig. 1). We found two distinct perforator vessels on the right and a very large perforator on the left side. Further perforator preparation was performed using monopolar and bipolar cautery alternatively. The deep epigastric vessels were harvested with the maximal length on both sides. We used the internal mammary vessels as recipient vessels on both sides.
www.PRSJournal.com
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Plastic and Reconstructive Surgery • May 2014
Fig. 1. Intraoperative photograph showing both hemi-DIEP flaps raised but still connected to the vascular system. Both breasts have been removed and the recipient vessels (i.e., internal mammary vessels) have been prepared. Note that the lateral portions of both flaps have already been discarded.
Arterial anastomoses were completed in end-to-end fashion using interrupted 8-0 nylon sutures (Monosof; Covidien, Mansfield, Mass.). For venous anastomosis, we used a coupler system (Synovis, St. Paul, Minn.) on both sides (3.0 mm). Donor-site closure was achieved by means of routine abdominoplasty closure. Two 19-French drains (Blake silicone drains; Ethicon, Inc., Somerville, N.J.) were placed under the undermined abdominoplasty flaps. The postoperative course was smooth and we were able to mobilize the patient on the third p ostoperative day. At 4-week follow-up, both hemi-DIEP flaps had survived fully, although there was limited hardening in the upper poles of the breast, suggesting minor fat necrosis (Fig. 2). However, no signs of infection or purulent discharge was noted. The patient was very satisfied with the outcome of the operation,
e specially with the increased mobility and amelioration of the clinical symptoms of the massive pannus. To the best of our knowledge, this is the first report of microsurgical breast reconstruction in a superobese patient (body mass index >50 kg/m2). Even though breast reconstruction with free flaps in obese patients is advised only with caution in the existing literature,1,3–5 in selected patients it is still a worthwhile endeavor. In such a patient, the profit of raising a flap from the lower abdomen is even higher compared with normal-weight women, as the abdominoplasty procedure for closure of the donor site often alleviates many of the problems associated with an overhanging pannus. It has been our experience, even though in a limited number of patients, that breast reconstruction in the obese yields more satisfactory and natural results when free tissue
Fig. 2. Preoperative photographs and 4-week postoperative result after bilateral breast reconstruction with hemi-DIEP flaps in a superobese patient (body mass index >50 kg/m2).
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Volume 133, Number 5 • Letters transfer is used. We agree that the aesthetic outcome is superior to what can be achieved with implant reconstruction alone. Nevertheless, patients have to be counseled accordingly, and the increased risks of delayed wound healing and increased total flap loss must be brought to their attention. However, even then, most of our obese patients opt for the more natural reconstruction using pure autologous tissue together with the added benefit of a pannus resection and relief of the corresponding symptoms. In the case presented here, this could be achieved in a very satisfactory manner. DOI: 10.1097/01.prs.0000438444.25035.04
Georg M. Huemer, M.D., M.Sc., M.B.A. Manfred Schmidt, M.D. Section of Plastic and Reconstructive Surgery Department of General Surgery General Hospital Linz, and maz – Microsurgical Training and Research Center Linz
Lorenz Larcher, M.D. Department of Plastic, Aesthetic and Reconstructive Surgery Hospital St. John of God Salzburg, Austria Correspondence to Dr. Huemer Section of Plastic and Reconstructive Surgery Department of General Surgery General Hospital Linz Krankenhausstrasse 9 4020 Linz, Austria [email protected]
DISCLOSURE Dr. Schmidt and Dr. Larcher have no financial interest in any of the products, or devices mentioned in this communication. Dr. Huemer serves on the speaker’s bureau of Covidien, which provided suture material. No funding was received for this work. REFERENCES 1. Fischer JP, Nelson JA, Sieber B, et al. Free tissue transfer in the obese patient: An outcome and cost analysis in 1258 consecutive abdominally based reconstructions. Plast Reconstr Surg. 2013;131:681e–692e. 2. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg. 1994;32:32–38. 3. Jandali S, Nelson JA, Sonnad SS, et al. Breast reconstruction with free tissue transfer from the abdomen in the morbidly obese. Plast Reconstr Surg. 2011;127:2206–2213. 4. Seidenstuecker K, Munder B, Mahajan AL, Richrath P, Behrendt P, Andree C. Morbidity of microsurgical breast reconstruction in patients with comorbid conditions. Plast Reconstr Surg. 2011;127:1086–1092. 5. Fischer JP, Nelson JA, Kovach SJ, Serletti JM, Wu LC, Kanchwala S. Impact of obesity on outcomes in breast reconstruction: Analysis of 15,937 patients from the ACS-NSQIP datasets. J Am Coll Surg. 2013;217:656–664.
Reply: Free Tissue Transfer in the Obese Patient: An Outcome and Cost Analysis in 1258 Consecutive Abdominally Based Reconstructions Sir:
We appreciate the letter by Huemer et al. regarding bilateral breast reconstruction with hemi–deep inferior epigastric perforator (DIEP) flaps in a superobese patient. The authors should be applauded for sharing their experience with abdominally based free tissue transfer in such a challenging patient. Assessing the outcomes and cost dynamics of autologous breast reconstruction in obese patients has become an area of particular interest at our institution. We have examined breast reconstruction in obese patients, and across levels of stratified obesity (World Health Organization), both at an institutional level1,2 and using national data sets (American College of Surgeons National Surgical Quality Improvement Program).3,4 These studies have demonstrated that obese patients tend to experience higher rates of surgical complications and that progressive obesity imparts added risk. However, we believe that despite the determination that obesity is an independent risk factor for morbidity, it should not be treated as an absolute contraindication for performing abdominally based autologous breast reconstruction. Our previous work has demonstrated that World Health Organization class III obesity is associated with higher rates of flap loss (5.5 percent) relative to nonobese and class I obese patients.2 In addition, the presence of obesity was shown to be independently associated with higher rates of wound morbidity. Our subgroup analysis demonstrated no statistically significant difference in hernia rates across obesity groups but did reveal a significantly lower rate of hernia (1.1 percent) when DIEP flaps were used relative to transverse rectus abdominis musculocutaneous flap procedures in obese patients. These findings underscore the importance of risk assessment, informed consent, and meticulous donor-site management in these challenging patient populations. The obese patient should be informed of the significantly higher risk for wound healing complications. In addition, the morbidly obese patient should be counseled regarding higher risk of flap loss, extended operating time, and postoperative hernia formation. Huemer et al. demonstrate the ability to perform bilateral DIEP flaps in a superobese patient (body mass index of 53.8 kg/m2). Such a fascia-sparing approach is optimal in terms of postoperative abdominal wall integrity and strength. However, this must be balanced with a potential for decreased perfusion to a large volume of tissue, which may ultimately result in fat necrosis. Having performed reconstruction on several patients with a body mass index greater than 50 kg/m2, we do not hesitate to sacrifice a small portion of the rectus muscle to maximize perfusion and reliability. Although class III obese patients are at higher risk for complications following autologous reconstruction,
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Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor. Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested. Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium. The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence. The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.
Letters Free Tissue Transfer in the Obese Patient: An Outcome and Cost Analysis in 1258 Consecutive Abdominally Based Reconstructions Sir:
W
e read with great interest the article by Fischer et al.1 published recently on breast reconstruction in the obese patient population. The deep inferior epigastric perforator (DIEP) flap has become a workhorse in autologous breast reconstruction2 and a very popular option for breast reconstruction because of the reduced donor-site morbidity and the additional benefit of an abdominoplasty, even more so in the obese patient with a distinct pannus. However, surgeons have to remain guarded over selecting patients for a DIEP flap procedure in the Copyright © 2014 by the American Society of Plastic Surgeons
presence of certain comorbid conditions. Obesity, especially class III obesity (body mass index >40 kg/m2), is a proven independent risk factor for complications during autologous breast reconstruction, with a higher risk of total flap loss, total major postoperative complications, and delayed abdominal wound healing.3 Interestingly, perforator flaps such as the DIEP flap or superficial inferior epigastric artery flap exhibit fewer postoperative donor-site complications compared with muscle-sparing transverse rectus abdominis muscle flaps, with comparable microsurgical outcomes.1 Therefore, the authors of the current study advise caution when offering this type of breast reconstruction to morbidly obese patients. In a different study, outcomes of breast reconstruction in over 600 patients were reviewed with a specific focus on comorbid conditions.4 The authors found a significantly increased rate of flap complications and a significantly higher rate of total flap loss, including donor-site complications in women with a body mass index greater than 30. However, they concluded that although patients should be advised to reduce their body weight, obesity should not be considered a contraindication to microsurgical breast reconstruction. Even in this patient cohort, DIEP flap reconstruction represents the technique of choice, with excellent aesthetic outcomes and high patient satisfaction. In light of these findings, we want to report our experience in bilateral microsurgical breast reconstruction in a superobese patient. A 44-year-old patient with a body mass index of 53.8 kg/m2 and with recurrence of a breast carcinoma on the right side presented to our service for autologous breast reconstruction. The patient had a positive family history of breast cancer (mother and grandmother) and with certain comorbid conditions such as diabetes mellitus, hypertension, hypothyroidism, extreme obesity with a massive abdominal pannus, and asthma bronchiale. Five years earlier, she underwent an oncoplastic resection of the upper exterior quadrant of the left breast with a simultaneous contralateral adaptive mastopexy and a sentinel lymph node biopsy in the left axilla. Postoperatively, the patient underwent radiotherapy and chemotherapy. Two years later, she had recurrence on both sides that was treated with lumpectomy. The patient presented to our office for breast reconstruction with bilateral hemi-DIEP flaps immediately following simultaneous bilateral mastectomy. The weight of the pannus was 4477 g; the weight of the left hemi-DIEP flap 1285 g and that of the right hemi-DIEP flap was 1314 g. Preoperatively, a perforator computed tomographic scan was obtained that showed good bilateral DIEP vessels. We first resected the lateral extensions of the pannus and proceeded to explore the perforator vessels on both sides under loupe magnification (Fig. 1). We found two distinct perforator vessels on the right and a very large perforator on the left side. Further perforator preparation was performed using monopolar and bipolar cautery alternatively. The deep epigastric vessels were harvested with the maximal length on both sides. We used the internal mammary vessels as recipient vessels on both sides.
www.PRSJournal.com
711e
Plastic and Reconstructive Surgery • May 2014
Fig. 1. Intraoperative photograph showing both hemi-DIEP flaps raised but still connected to the vascular system. Both breasts have been removed and the recipient vessels (i.e., internal mammary vessels) have been prepared. Note that the lateral portions of both flaps have already been discarded.
Arterial anastomoses were completed in end-to-end fashion using interrupted 8-0 nylon sutures (Monosof; Covidien, Mansfield, Mass.). For venous anastomosis, we used a coupler system (Synovis, St. Paul, Minn.) on both sides (3.0 mm). Donor-site closure was achieved by means of routine abdominoplasty closure. Two 19-French drains (Blake silicone drains; Ethicon, Inc., Somerville, N.J.) were placed under the undermined abdominoplasty flaps. The postoperative course was smooth and we were able to mobilize the patient on the third p ostoperative day. At 4-week follow-up, both hemi-DIEP flaps had survived fully, although there was limited hardening in the upper poles of the breast, suggesting minor fat necrosis (Fig. 2). However, no signs of infection or purulent discharge was noted. The patient was very satisfied with the outcome of the operation,
e specially with the increased mobility and amelioration of the clinical symptoms of the massive pannus. To the best of our knowledge, this is the first report of microsurgical breast reconstruction in a superobese patient (body mass index >50 kg/m2). Even though breast reconstruction with free flaps in obese patients is advised only with caution in the existing literature,1,3–5 in selected patients it is still a worthwhile endeavor. In such a patient, the profit of raising a flap from the lower abdomen is even higher compared with normal-weight women, as the abdominoplasty procedure for closure of the donor site often alleviates many of the problems associated with an overhanging pannus. It has been our experience, even though in a limited number of patients, that breast reconstruction in the obese yields more satisfactory and natural results when free tissue
Fig. 2. Preoperative photographs and 4-week postoperative result after bilateral breast reconstruction with hemi-DIEP flaps in a superobese patient (body mass index >50 kg/m2).
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Volume 133, Number 5 • Letters transfer is used. We agree that the aesthetic outcome is superior to what can be achieved with implant reconstruction alone. Nevertheless, patients have to be counseled accordingly, and the increased risks of delayed wound healing and increased total flap loss must be brought to their attention. However, even then, most of our obese patients opt for the more natural reconstruction using pure autologous tissue together with the added benefit of a pannus resection and relief of the corresponding symptoms. In the case presented here, this could be achieved in a very satisfactory manner. DOI: 10.1097/01.prs.0000438444.25035.04
Georg M. Huemer, M.D., M.Sc., M.B.A. Manfred Schmidt, M.D. Section of Plastic and Reconstructive Surgery Department of General Surgery General Hospital Linz, and maz – Microsurgical Training and Research Center Linz
Lorenz Larcher, M.D. Department of Plastic, Aesthetic and Reconstructive Surgery Hospital St. John of God Salzburg, Austria Correspondence to Dr. Huemer Section of Plastic and Reconstructive Surgery Department of General Surgery General Hospital Linz Krankenhausstrasse 9 4020 Linz, Austria [email protected]
DISCLOSURE Dr. Schmidt and Dr. Larcher have no financial interest in any of the products, or devices mentioned in this communication. Dr. Huemer serves on the speaker’s bureau of Covidien, which provided suture material. No funding was received for this work. REFERENCES 1. Fischer JP, Nelson JA, Sieber B, et al. Free tissue transfer in the obese patient: An outcome and cost analysis in 1258 consecutive abdominally based reconstructions. Plast Reconstr Surg. 2013;131:681e–692e. 2. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg. 1994;32:32–38. 3. Jandali S, Nelson JA, Sonnad SS, et al. Breast reconstruction with free tissue transfer from the abdomen in the morbidly obese. Plast Reconstr Surg. 2011;127:2206–2213. 4. Seidenstuecker K, Munder B, Mahajan AL, Richrath P, Behrendt P, Andree C. Morbidity of microsurgical breast reconstruction in patients with comorbid conditions. Plast Reconstr Surg. 2011;127:1086–1092. 5. Fischer JP, Nelson JA, Kovach SJ, Serletti JM, Wu LC, Kanchwala S. Impact of obesity on outcomes in breast reconstruction: Analysis of 15,937 patients from the ACS-NSQIP datasets. J Am Coll Surg. 2013;217:656–664.
Reply: Free Tissue Transfer in the Obese Patient: An Outcome and Cost Analysis in 1258 Consecutive Abdominally Based Reconstructions Sir:
We appreciate the letter by Huemer et al. regarding bilateral breast reconstruction with hemi–deep inferior epigastric perforator (DIEP) flaps in a superobese patient. The authors should be applauded for sharing their experience with abdominally based free tissue transfer in such a challenging patient. Assessing the outcomes and cost dynamics of autologous breast reconstruction in obese patients has become an area of particular interest at our institution. We have examined breast reconstruction in obese patients, and across levels of stratified obesity (World Health Organization), both at an institutional level1,2 and using national data sets (American College of Surgeons National Surgical Quality Improvement Program).3,4 These studies have demonstrated that obese patients tend to experience higher rates of surgical complications and that progressive obesity imparts added risk. However, we believe that despite the determination that obesity is an independent risk factor for morbidity, it should not be treated as an absolute contraindication for performing abdominally based autologous breast reconstruction. Our previous work has demonstrated that World Health Organization class III obesity is associated with higher rates of flap loss (5.5 percent) relative to nonobese and class I obese patients.2 In addition, the presence of obesity was shown to be independently associated with higher rates of wound morbidity. Our subgroup analysis demonstrated no statistically significant difference in hernia rates across obesity groups but did reveal a significantly lower rate of hernia (1.1 percent) when DIEP flaps were used relative to transverse rectus abdominis musculocutaneous flap procedures in obese patients. These findings underscore the importance of risk assessment, informed consent, and meticulous donor-site management in these challenging patient populations. The obese patient should be informed of the significantly higher risk for wound healing complications. In addition, the morbidly obese patient should be counseled regarding higher risk of flap loss, extended operating time, and postoperative hernia formation. Huemer et al. demonstrate the ability to perform bilateral DIEP flaps in a superobese patient (body mass index of 53.8 kg/m2). Such a fascia-sparing approach is optimal in terms of postoperative abdominal wall integrity and strength. However, this must be balanced with a potential for decreased perfusion to a large volume of tissue, which may ultimately result in fat necrosis. Having performed reconstruction on several patients with a body mass index greater than 50 kg/m2, we do not hesitate to sacrifice a small portion of the rectus muscle to maximize perfusion and reliability. Although class III obese patients are at higher risk for complications following autologous reconstruction,
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